Monday, April 20, 2009

"Whomever pays the piper calls the tune" goes the (once-popular) adage. And that makes a certain amount of sense: if, for example, the government is paying for one's health care (which, of course, it's not; the taxpayer foots the bill), then the government has a stake in both the cost and outcome of that care.

I don't much disagree with that.

But that then begs the question of whether or not we should have the choice of opting out of such a system. As we've seen, when the gummint controls health care (and the funding thereof), it gets to "call the tune" in ways that folks may not have envisioned. Which brings us to the point of all these questions: if the gummint runs the health care system, does that mean it gets to override the advice and concerns of one's own physician?

Now it's important to remember that the state didn't (and thus far, can't) prohibit Callie from receiving the extra 10 hours, but it can certainly refuse to pay for them. And so it has. Since I'm not a doctor (nor do I play one on TV), I won't pass judgment on whether or not the disputed 10 hours are "medically necessary;" but certainly when the state deems them not to be, it's very difficult to "fight city hall."

Now, astute readers may observe that insurance carriers also have a say in whether or not the cost of care will be reimbursed. And that's true: if you've ever filed a claim, you know that the insurer will "reprice" it based on the rates they've previously negotiated with the provider. And sometimes, they'll deny a claim (or pay a reduced amount) based on medical necessity.

But there are some important distinctions: first, the contract itself is agreed to by the parties (the insurer and the insured), they are subject to several appeals processes, and, ultimately, the insurer may be sued by the insured or even fined by the state.

Meanwhile, one can shop around for a different carrier.

There are, in short, choices.

A gummint-sponsored plan, however, offers few of these safeguards, and no choices. The plans are not flexible, one doesn't get to see a policy, and the insured has two choices: abide by the decisions or forego the coverage. An insurer may well have "deep pockets," but they don't have bottomless ones. Not so with the state, which has powers far beyond those of mere insurers.

Callie's parents fought the decision in court, and won. Instead of abiding by the decision, however, three states are fighting it:

Again, readers may argue that insurers make these kinds of decisions, as well, and they'd be correct. But insurers employ legions of medical folks, from CMO's to on-call nurses, to help make them. The state doesn't. There's no question that insurers make bone-headed decisions (one has only to read our on-going Stupid Carrier Tricks series for proof of that); but they are usually held to account for them, and the state has the power to change those decisions, and to enforce those changes.

But who enforces the enforcers?

If the state is the sole source of medical insurance, let alone the sole source of medical care, then who or what has the means to hold those bureaucrats' feet to the fire? That's the danger of socialized, government-run health care, and little Callie may indeed be the poster child for refusing it.

"Whomever pays the piper calls the tune" goes the (once-popular) adage. And that makes a certain amount of sense: if, for example, the government is paying for one's health care (which, of course, it's not; the taxpayer foots the bill), then the government has a stake in both the cost and outcome of that care.

I don't much disagree with that.

But that then begs the question of whether or not we should have the choice of opting out of such a system. As we've seen, when the gummint controls health care (and the funding thereof), it gets to "call the tune" in ways that folks may not have envisioned. Which brings us to the point of all these questions: if the gummint runs the health care system, does that mean it gets to override the advice and concerns of one's own physician?

Now it's important to remember that the state didn't (and thus far, can't) prohibit Callie from receiving the extra 10 hours, but it can certainly refuse to pay for them. And so it has. Since I'm not a doctor (nor do I play one on TV), I won't pass judgment on whether or not the disputed 10 hours are "medically necessary;" but certainly when the state deems them not to be, it's very difficult to "fight city hall."

Now, astute readers may observe that insurance carriers also have a say in whether or not the cost of care will be reimbursed. And that's true: if you've ever filed a claim, you know that the insurer will "reprice" it based on the rates they've previously negotiated with the provider. And sometimes, they'll deny a claim (or pay a reduced amount) based on medical necessity.

But there are some important distinctions: first, the contract itself is agreed to by the parties (the insurer and the insured), they are subject to several appeals processes, and, ultimately, the insurer may be sued by the insured or even fined by the state.

Meanwhile, one can shop around for a different carrier.

There are, in short, choices.

A gummint-sponsored plan, however, offers few of these safeguards, and no choices. The plans are not flexible, one doesn't get to see a policy, and the insured has two choices: abide by the decisions or forego the coverage. An insurer may well have "deep pockets," but they don't have bottomless ones. Not so with the state, which has powers far beyond those of mere insurers.

Callie's parents fought the decision in court, and won. Instead of abiding by the decision, however, three states are fighting it:

Again, readers may argue that insurers make these kinds of decisions, as well, and they'd be correct. But insurers employ legions of medical folks, from CMO's to on-call nurses, to help make them. The state doesn't. There's no question that insurers make bone-headed decisions (one has only to read our on-going Stupid Carrier Tricks series for proof of that); but they are usually held to account for them, and the state has the power to change those decisions, and to enforce those changes.

But who enforces the enforcers?

If the state is the sole source of medical insurance, let alone the sole source of medical care, then who or what has the means to hold those bureaucrats' feet to the fire? That's the danger of socialized, government-run health care, and little Callie may indeed be the poster child for refusing it.